In Colombia, the general health and social security system is a model financed with public resources and managed by payers, mainly private. The insurers and providers follow a very broad and strict legislation, with the obligation to comply with technical guidelines and the efficient use of resources, taking care of the health of the healthy person, controlling the chronic patient and seeking to provide timely care to the acute patient. The COVID-19 pandemic put all healthcare systems of the world to the test, and, even with all the opportunities for improvement, our system has come out well to date, which endorses the permanent willingness of all the actors to work strongly in evolving and progressively correcting the shortcomings.
In the last 4 years, the National Health Superintendence has liquidated 13 insurers1. The non-compliance with the financial and management conditions by these entities has an impact on the clinical care of their users, which makes that the ability to respond effectively to the obligations in relation to the other actors in the system is lost and that the quality of life of the affiliates is notoriously affected. The main causes of the financial insufficiencies arise from strategy mistakes of the management teams, conceptual difficulties of the care model and operational ineffectiveness of the decisions made.
On the other hand, the insurers and providers that have managed to maintain themselves in a good position over time have as a common denominator an adequate philosophical, conceptual and operational construction of the care model, always within the regulatory framework with all the components, and that by dint of necessity the State has had to build. These components are based on the proper characterization of the population in epidemiological terms and of consumption of services and costs associated with care, information on the quality of care and health risk management of specific populations, as well as case management strategies for patients with high-cost diseases.
Of particular interest is the definition of this care model in the management of chronic non-communicable diseases, responsible for the death of 5.5 million people a year in the Americas region. Of such deaths, 2.2 million occur before the age of 70, according to official information from the Pan American Health Organization2. Added to this great impact is the complexity of the comprehensive care process for these diseases, which includes the preventive management of the risk factors associated with their development, the need for a basic level of care that is strong in early detection and timely diagnosis (before the presence of complications), and, especially, comprehensive treatment, guided by a specialist when necessary, but which must always have an interdisciplinary team that helps the patients navigate in a simple and reliable way to achieve long lasting control of their condition.
This entire progressive scenario causes the care models to evolve and the needs of the insurers to change. The practice of medicine is increasingly ambulatory and home-based, leaving hospital issues for extremely complex managements, or, eventually, for studying patients with difficult diagnoses, even including surgical settings.
The care models by specialties are becoming more relevant and it is not easy to build them with the operational scopes that meet all the definitions needed today: evidence-based and cost-effective services, opportunity and access of the highest quality and measurement of outcomes that include health outcomes, which must be objective from a clinical point of view and include reports on the user experience and perception of quality of life and other outcomes. It is becoming more and more palpable in the world that if we want to have truly patient-centered models of care, the voice of the patient must be heard systematically in the decision-making3. We are facing still a long road ahead in Colombia, although the conditions are given to do it.
In this sense, the appearance of Decree 441 of 2022 continues to provide clarity in definitions and tools necessary for a proper contracting between insurers and providers, taking into account that this contracting process is what brings the dreamed care model to reality. The specification of the concept of technical note, the inclusion of care guidelines and protocols, as well as the user protection mechanisms, undoubtedly clarify and help to achieve the transparency of the information necessary for the stability of the processes and the win-win for all the actors. The next steps in this scenario are: 1) that the audit component validates the execution and the results of these models, and 2) no less importantly, define Colombia's willingness to pay for new technologies. The next steps in this scenario are: 1) that the audit component validates its execution and the results of these models, and 2) no less importantly, to define what is the willingness of Colombia to pay for new technologies. The resources are finite.
Finally, all these adjustments that are taking place in the health system make it necessary, as in other sectors, to develop and apply the tools of the fourth industrial revolution, in such a way that advanced technologies for the production of health services are combined with intelligent technologies that integrate organizations, people and assets. The integration of tools such as robotics, analytics, artificial intelligence, cognitive technologies, nanotechnology, among many others, must begin their development and help the progressive maturation of the health system and the care model, as is already beginning to happen in other countries.
Please cite this article as: Arévalo Roa HO, Guarín Téllez N. El modelo de atención como piedra angular de los resultados ensalud de los pacientes crónicos. Rev Colomb Reumatol. 2022;29:155–156.
